Comprehensive Healthcare Inspection of the Manchester VA Medical Center in New Hampshire

This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program report provides a focused evaluation of the quality of care delivered in the outpatient settings of the Manchester VA Medical Center. The inspection covered key clinical and administrative processes that are associated with promoting quality care. It focused on Leadership and Organizational Risks; COVID-19 Pandemic Readiness and Response; Quality, Safety, and Value; Registered Nurse Credentialing; Mental Health: Emergency Department and Urgent Care Center Suicide Risk Screening and Evaluation; Care Coordination: Inter-facility Transfers; and High-Risk Processes: Management of Disruptive and Violent Behavior. The leadership team appeared stable, with a vacancy in only one of four key positions. Employee survey data revealed satisfaction with leadership and a workplace where staff felt respected and discrimination was not tolerated. However, the OIG noted opportunities to improve servant leadership behaviors and reduce staff feelings of moral distress at work. Patient experience survey results indicated opportunities to improve female veterans’ satisfaction in the outpatient settings. The OIG’s review of the healthcare system’s accreditation findings, sentinel events, and disclosures of adverse patient events did not identify any substantial organizational risk factors. Executive leaders were generally knowledgeable about selected data used in Strategic Analytics for Improvement and Learning models and should continue to take actions to improve performance. The OIG issued seven recommendations for improvement in three areas: (1) Quality, Safety, and Value • Surgical work group attendance (2) Care Coordination • Monitoring and evaluation of patient transfers • Transfer form completion • Medication list transmission • Nurse-to-nurse communication (3) High-Risk Processes • Disruptive behavior committee attendance • Staff training